From the University of California, San Francisco, and San Francisco General Hospital, San Francisco, California; University of Washington School of Medicine, Seattle, Washington; Dartmouth–Hitchcock Medical Center, Lebanon, New Hampshire; University of Pennsylvania, Philadelphia, Pennsylvania; Oregon Health and Science University, Portland, Oregon; and Beth Israel Medical Center, New York, New York.

J. Randall Curtis, MD, MPH

From the University of California, San Francisco, and San Francisco General Hospital, San Francisco, California; University of Washington School of Medicine, Seattle, Washington; Dartmouth–Hitchcock Medical Center, Lebanon, New Hampshire; University of Pennsylvania, Philadelphia, Pennsylvania; Oregon Health and Science University, Portland, Oregon; and Beth Israel Medical Center, New York, New York.

Leslie E. Wolf, JD, MPH

From the University of California, San Francisco, and San Francisco General Hospital, San Francisco, California; University of Washington School of Medicine, Seattle, Washington; Dartmouth–Hitchcock Medical Center, Lebanon, New Hampshire; University of Pennsylvania, Philadelphia, Pennsylvania; Oregon Health and Science University, Portland, Oregon; and Beth Israel Medical Center, New York, New York.

Thomas J. Prendergast, MD

From the University of California, San Francisco, and San Francisco General Hospital, San Francisco, California; University of Washington School of Medicine, Seattle, Washington; Dartmouth–Hitchcock Medical Center, Lebanon, New Hampshire; University of Pennsylvania, Philadelphia, Pennsylvania; Oregon Health and Science University, Portland, Oregon; and Beth Israel Medical Center, New York, New York.

Darren B. Taichman, MD, PhD

From the University of California, San Francisco, and San Francisco General Hospital, San Francisco, California; University of Washington School of Medicine, Seattle, Washington; Dartmouth–Hitchcock Medical Center, Lebanon, New Hampshire; University of Pennsylvania, Philadelphia, Pennsylvania; Oregon Health and Science University, Portland, Oregon; and Beth Israel Medical Center, New York, New York.

Gary Kuniyoshi, MD

From the University of California, San Francisco, and San Francisco General Hospital, San Francisco, California; University of Washington School of Medicine, Seattle, Washington; Dartmouth–Hitchcock Medical Center, Lebanon, New Hampshire; University of Pennsylvania, Philadelphia, Pennsylvania; Oregon Health and Science University, Portland, Oregon; and Beth Israel Medical Center, New York, New York.

Frank Acerra, DO

From the University of California, San Francisco, and San Francisco General Hospital, San Francisco, California; University of Washington School of Medicine, Seattle, Washington; Dartmouth–Hitchcock Medical Center, Lebanon, New Hampshire; University of Pennsylvania, Philadelphia, Pennsylvania; Oregon Health and Science University, Portland, Oregon; and Beth Israel Medical Center, New York, New York.

Bernard Lo, MD

From the University of California, San Francisco, and San Francisco General Hospital, San Francisco, California; University of Washington School of Medicine, Seattle, Washington; Dartmouth–Hitchcock Medical Center, Lebanon, New Hampshire; University of Pennsylvania, Philadelphia, Pennsylvania; Oregon Health and Science University, Portland, Oregon; and Beth Israel Medical Center, New York, New York.

John M. Luce, MD

From the University of California, San Francisco, and San Francisco General Hospital, San Francisco, California; University of Washington School of Medicine, Seattle, Washington; Dartmouth–Hitchcock Medical Center, Lebanon, New Hampshire; University of Pennsylvania, Philadelphia, Pennsylvania; Oregon Health and Science University, Portland, Oregon; and Beth Israel Medical Center, New York, New York.

From the University of California, San Francisco, and San Francisco General Hospital, San Francisco, California; University of Washington School of Medicine, Seattle, Washington; Dartmouth–Hitchcock Medical Center, Lebanon, New Hampshire; University of Pennsylvania, Philadelphia, Pennsylvania; Oregon Health and Science University, Portland, Oregon; and Beth Israel Medical Center, New York, New York.

Grant Support: By National Institutes of Health grants KL2 RR024130 from the National Center for Research Resources, a component of the National Institutes of Health Roadmap for Medical Research (Dr. White); K24 HL 68593 (Dr. Curtis); and MH 42459 (Ms. Lo). Ms. Lo and Dr. Wolf were also supported by the Greenwall Foundation.

Abstract

Background:

Physicians in intensive care units have withdrawn life support in incapacitated patients who lack surrogate decision makers and advance directives, yet little is known about how often this occurs or under what circumstances.

Objective:

To determine the proportion of deaths in intensive care units that occur in patients who lack decision-making capacity and a surrogate and the process that physicians use to make these decisions.

Design:

Multicenter, prospective cohort study.

Setting:

Intensive care units of 7 medical centers in 2004 to 2005.

Patients:

3011 consecutive critically ill adults.

Measurements:

Attending physicians completed a questionnaire about the decision-making process for each incapacitated patient without a surrogate or advance directive for whom they considered limiting life support.

Results:

Overall, 5.5% (25 of 451 patients) of deaths in intensive care units occurred in incapacitated patients who lacked a surrogate decision maker and an advance directive. This percentage ranged from 0% to 27% across the 7 centers. Physicians considered limiting life support in 37 such patients or would have considered it if a surrogate had been available. In 6 patients, there was prospective hospital review of the decision, and in 1 patient, there was court review. In the remaining 30 patients, the decision was made by the intensive care unit team alone or by the intensive care unit team plus another attending physician. The authors found wide variability in hospital policies, professional society guidelines, and state laws regarding who should make life-support decisions for this patient population. Thirty-six of 37 life-support decisions were made in a manner inconsistent with American College of Physicians guidelines for judicial review.

Limitations:

The results are based on physicians' self-reported practices and may not match actual practices. The number of incapacitated patients without surrogates in the study is small.

Conclusions:

Incapacitated patients without surrogates accounted for approximately 1 in 20 deaths in intensive care units. Most life-support decisions were made by physicians without institutional or judicial review.